Summary On the afternoon of 09 January 2001, the Panama-flag container ship Alligator Victory departed from its berth at Deltaport, Vancouver, British Columbia. Soon after, the deck crew began the routine task of raising the starboard-side accommodation ladder to its stowage position in preparation for the vessel's trans-Pacific voyage. The operation was almost complete when a pad eye, welded to a supporting steel deck post, broke in two. This sudden fracture violently released a steel snatch block that was shackled to the pad eye. The snatch block then struck and killed a member of the crew. Ce rapport est galement disponible en franais. Other Factual Information Particulars of the Vessel Description of the Vessel The Alligator Victory was built in February 1988 in Japan as a container vessel and is designed to carry 2912 twenty-foot equivalent units. The wheelhouse, the accommodation block, and the engine room are at the after end of the ship. The containers are carried in cargo holds and on deck, both forward of and abaft the accommodation block in an arrangement common to container ships. The vessel carries two accommodation ladders (gangways) outboard of the accommodation, one ladder on either side of the vessel block. Two other accommodation ladders, used mainly for embarking and disembarking the pilot, are near midships. Accommodation Ladders The accommodation ladder is stored on the ship and is considered an attachment. It provides access to the ship and enables its personnel, stevedores, and officials to embark and disembark. The accommodation ladder was rigged as shown in Figure 1. Figure 1. Typical arrangement of an accommodation ladder, its falls, and its winch. N.B.: Actual arrangement will vary from vessel to vessel. See Figure 2 for the location of the snatch block and figures 3 and 4 for that of the broken pad eye. The falls are reeved through sets of sheaves that are fixed to a davit arm, one end of which is hinged to the deck. Through another system of sheaves and snatch blocks mounted on various deck and side posts, the falls are wound around the drums of an electric winch. To hold the .winch, and thence the ladder, in its last set position, the electric motor has an electromagnetic disc brake. A second manual band brake, intended for emergency use in case the main brake fails, is also fitted around one of the winch drums. When the winch is used for hoisting the ladder, the falls wrap themselves around a drum and the ladder moves from its inclined position toward the horizontal, pivoting about its hinge on the turntable. Figure 2. Location of broken pad eye and snatch block. Snatch blocks are arranged above and inboard of the ladder. Any additional hauling in of the falls turns the entire ladder and the turntable sideways. The complete assembly now pivots about the hinge between the turntable and the deck, until the assembly becomes vertical and lies on its side. The assembly can now be secured for an ocean passage. The ladder's and the turntable's stowed position is vertical, inboard of the ship side but outboard of the railings (Figure 2). Accommodation Ladder Maintenance The vessel has an internal planned maintenance program, set up to meet anticipated International Safety Management Code (ISM Code) requirements. The plan does not specify inspection and overhauling of the accommodation ladder's various components. Instead, maintenance on accommodation ladders was limited to general chipping, painting, and renewal of falls. Under this program, the falls had been renewed on 06 October 2000. In July 2000, this gangway had been chipped and repainted, and the sheaves, pulleys, and other deck fittings had been greased. All the work had been done on site; there are no records to indicate that the electric motor, the davit and its sheaves, or the turntable had ever been routinely dismantled and overhauled. Description of the Accident The Alligator Victory finished discharging and loading its cargo of containers at Deltaport on the morning of 09 January 2001. The pilot boarded the vessel at 1200 and, after completing all required formalities, it was ready to depart by 1201. Once all the officials were off the ship, the deck crew lifted the gangway off the jetty and into a horizontal position well away from any shore-side obstructions. In this position, the gangway would not hinder the tugs in their operations. Some of the crew members and the second officer then went to their aft stations on the poop deck, where they let go the stern lines and made fast a tug. By 1220, the ship was clear of the berth and was moving ahead. The tugs had been cast off, and the second officer instructed his crew to finish stowing the accommodation ladder in preparation for the voyage. One of the crew members operated the controls of the electric winch while another stood under the snatch block by the railings, watching the ascent of the ladder and guiding the operator. Just before the gangway reached its final stowage position, the pad eye securing the snatch block to the side post suddenly parted. The abrupt releasing of the snatch block, when there was still tension on the falls, caused it to swing violently outward and strike the seaman standing in its path. Though he was wearing a hard hat, the snatch block hit him on the forehead and face; he later succumbed to his injuries. Ship damage was limited to one broken pad eye. Other Observations Though not related to the accident but indicative of the general condition of the accommodation ladder, other observations were made as follows: the band brake around the winch motor was found broken the securing pin on the lock nut of the central pin of the turntable was missing there was scale and corrosion built up around the lock nut, the pin, and on some sheaves the underside of the davit arm was corroded in certain places the side plates of the sheaves attached to the davit arm bore signs of contact with other external objects Vessel and Crew Certification The vessel was crewed and equipped in accordance with existing regulations for a vessel of its type and for the trade in which it was engaged. The vessel had a voluntary, internal safety management system and audit procedure, wherein nonconformities were identified and corrective action procedures initiated and executed. The vessel did not have a Safety Management Certificate (it did not have to comply with the ISM Code requirements until 01July 2002), but its management company had been issued a Document of Compliance by Nippon Kaiji Kyokai in February 1998. Other Occurrence Involving an Accommodation Ladder On 05 February 1999, the Arabella was at anchor in English Bay, British Columbia, and disembarked six persons from the vessel and onto a waiting water taxi. While five of them were on the accommodation ladder, its turntable separated from its upper platform, catapulting two of them off the ladder and into the water. One of them bounced off the water taxi's bow and, as a result, sustained serious injuries. A subsequent investigation by the TSB (Report N0 M99W0017) revealed the following: The construction of the accommodation ladder did not conform to the vessel's drawings or specifications. The port and starboard ladders differed in construction. The construction of the port-side accommodation ladder's turntable did not allow for regular inspection or for lubrication of the central pivot pin. Lack of lubrication led to the pivot pin deteriorating to a point where it seized in its housing. Finally, under the influence of external applied forces, it sheared in two.